Fact check cesarean: risk or rescue? | Science| In-depth reporting on science and technology | DW | 11.05.2018
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Fact check cesarean: risk or rescue?

In many industrialized countries, the cesarean rate has risen over the last 20 years and the WHO has recommended reducing it. Doctors and midwives are in demand, but also expectant mothers.

In which countries is cesarean widespread?

One in every four children born in the most parts of Europe, Asia and America is done so by cesarean section - in Germany, it is every third child and in Brazil even every second child. In contrast, the cesarean section rate is extremely low in Sub-Saharan Africa. Niger, Chad, Ethiopia, Burkina Faso and Madagascar have the lowest rates. Only two percent of all children are born by cesarean section in these countries — in other words less than two of 100.

Read more: Elective C-section births on the rise in Kenya

Which cesarean section rate is the 'right' one?

From 10 to 15 percent is the cesarean rate recommended by the WHO, as it approximately correlates with the number of births in which a cesarean could save the life of mother and child. A WHO report which compared how babies are born in 137 countries, showed that only 14 of the investigated countries fulfilled the WHO guideline. This included Ukraine, Namibia, Guatemala and Saudi Arabia.

In all other countries, the knife, it reported, is used too often (for example in Germany, Egypt, Turkey, USA) or too seldom. Exactly those countries with the highest birth rates have the lowest cesarean rates. That’s primarily due to financial reasons. The countries with the lowest cesarean rate also belong to the poorest countries worldwide.

Once cesarean, forever cesarean?

One reason for the high cesarean rate in many countries is based on the motto ‘once cesarean, forever cesarean,’ even when there are no complications with the pregnancy. In fact, an old cesarean scar can tear during the struggle of a second natural birth. That happens, however, very seldom. As soon as there is a time difference of two years between the births, the risk for such a crack is under one percent. When everything goes well with the mother and child, a natural birth can also work well after a cesarean. Also twins and breech babies can be born naturally. A good medial team and a well experienced midwife are vital for that.

What are the risks after a cesarean for the mother?

In many countries with a good health system, the planned cesarean of the first baby is no longer a problem today. The difficulties, however, may occur afterwards. For instance, the risk of a placenta displacement increases with every cesarean. Also the risks for bleeding, thrombosis and adhesions are higher after a cesarean section than after a natural birth. With each subsequent cesarean, the birth becomes more dangerous for the mother. It's particularly problematic in regions where women traditionally have more children.

For some women, it becomes difficult to get pregnant after a cesarean. That is because adhesions can form in the uterus through the scar of the operation. A decrease of the fertility lies at 17 percent after a cesarean.

What are the risks for the child after a cesarean?

According to a study by Barmer, a health insurer, most women who would like to deliver their babies through a cesarean, do so because they are worried about their child and not because a cesarean is easier to preplan. They don't want to confront their babies with the stress of a natural birth. Labor pains and the whole birth process are actually good for the baby. They help them to convert their metabolism.

In the uterus, the lungs of the embryo are full of water. Only after the birth is the fluid pressed out and the lungs can convert to air breathing. The cesarean prevents this gradual procedure and surprises the baby with the birth. Therefore, many babies have a lot of problems after a cesarean and must receive artificial respiration and are often transferred to intensive care. In the long term, cesarean babies have a high risk of asthma, diabetes, allergies and other auto-immune diseases.  

Do clinics have financial benefits from cesareans?

In the most countries, cesareans cost more than natural births. In Germany, a physician can charge €1,000 ($1,200) more for a cesarean than a natural birth. The intervention has also higher costs for the hospital. So the bottom line is it's not worth it for the hospitals. But cesareans are easier to preplan and therefore more efficient. That is an important factor for hospital management.

Midwifery is not well paid in Germany and it doesn't benefit the hospitals. Therefore, many maternity clinics have been closed since the 1990s and this trend continues even though the birth rate is rising.

Is labor induction a problem?

These days, women are given less time to give birth. Once they enter hospital, they get put on a drip automatically and if the cervix doesn't open one centimeter per hour, the physicians will medically induce labor. They thus accelerate the birth. In addition to that, the number of midwives has declined drastically. This is the case at least in Germany. While the number of nurses in a hospital is regulated, the number of midwives is a matter of discretion. One-to-one care that gives the woman a feeling of security during the birth is increasingly rare. Also the WHO has recognized this trend and recommends in its new guidelines less interventions and better care.

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